A patient said to her psychotherapist, "I
know that I'm intelligent, I have courage, and my opinions are as good as
anyone else's. Just knowing this has made a big difference in my whole
life. I can see the good things I've given my children, not just the bad
things. I think I even love them and my husband a lot more now." Another
patient said, "You know, Doc, for the first time in my life, 1 like
myself. I'm not half so bad a guy as I always felt I was." A shy girl had
written poems all her life; they represented her ego ideal, her hopes and
her dreams, but she could not believe in herself enough to let others see
them. With much anxiety
she showed some of them to her therapist. At his response-they were of
very high caliber-she began to accept her own value as a person, and to
talk hopefully about publishing her poetry. A brilliant woman
with special skills in
theoretical research had been blocked completely for nine years in her
ability to do work in her field and was filled with self-doubt and
self-dislike. One day she said with triumph and joy, "I started work on an
article last night I have it mapped out and the first two pages written. I
think it's going to be pretty good." A 39-year-old woman who had never had
a love relationship told her therapist one Monday morning of her wonderful
week end at the beach with a man she had met six months previously. As
they had watched the sun go down, she had felt inside like the colors of
the sunset The affair begun that night was one of deep meaning to both of
them, and she was able to give and receive the kind of love she had never
known existed.
Each of these patients was dying from
cancer. None of them lived more than one year after the reported incident,
and three died within four months.
In the course of a research project into
the relationships between personality and neoplastic disease, these
patients and others were given the opportunity of intensive psychotherapy
after their cancers had been diagnosed. Conducting over 3,500 hours of
therapy with these patients brought their needs and what psychotherapy can
hope to accomplish in such conditions into sharp focus.
There can be great value to the patient in
the fact of someone's believing in him enough to really work to help him
toward greater self-understanding and inner growth at a time when he
cannot 'repay' by a long period of adequate functioning--cannot "do as I
tell you to and grow up to be a big, strong, successful man." His being is
cared for unconditionally, and so he cares for it himself. The presence
of the therapist affirms the importance of the here and now. Life no
longer primarily seems to have the quality of something that is fading
away, but take4 on near meaning and validity. In the search for himself,
in the adventure of overcoming his psychic handicaps and crippling, the
patient may find a meaning its life that he never had found before. If the
psychotherapy focuses on his strengths and positive qualities and what has
blocked. their full expression, rather than on pathology-as Is so often
unfortunately the case in psychotherapy-the patient may come more and
more to value and to accept himself, and to accept his universe and his
fate. Frequently the patient who is dying has lost his cathexes, by the
natural attrition of life, by inner neurotic dictates, by an attempt on
his part and on the part of those closest to him to "spare" each other
from discussion of their mutual knowledge, or sometimes by a partial
withdrawal in a magical attempt to ease the pain of the final parting. He
is, therefore, very much alone and isolated in a universe which, because
of his isolation, seems hosted and uncaring-as Pascal said, "The eternal
silence of these infinite spaces frightens me." 1 The
therapist, by his presence and by his real interest, can give the patient
meaning through warm human contact, can, by providing the opportunity for
a strong cathexis, give him an anchor rope to the world and to others, so
that with Bruno and Goethe, he can feel that "out of this world we cannot
fall." 2 Or, like Camus's "stranger," when he had asserted, in
the only way he knew, his oneness with humanity and was close to death,
the patient can lay his ear "upon the benignly indifferent universe" and
feel how like himself, "how warm, friendly and brotherly" it is.• With
contact and connectedness returned, and with the focus on life rather
than on death, the patient's fear of death seems to diminish considerably.
In inexorable reality situations, the fear
of death-and with it guilt and self contempt--seems usually- to be related
to a sense of never having lived fully in one's
own way, of never
having sung the unique song of one's own personality. Thus it is by the
quest for one's own essence-by finding and engaging in one's own type of
relationships and activities that the fear
of death may, perhaps, lie
most successfully eased. This view-was empirically developed in this
research, but it is not new; it was advanced by Montaigne,, and
perhaps it is only a restatement of Epicurus "Where life is, death is
not."
Psychotherapy, for the patient who is aware
that "time's winged chariot" is hurrying him on, cannot deal only with the
technical aspects of personality as they are found in the textbooks. The
larger questions are too pressing, too imminent. Values must be explored.
As one patient put it, "Once the big questions are asked, you can't forget
them. You car. only ignore them as long as no one raises them." Death, the
figure in the background, asks the questions, and the therapist must join
in the search for answers which are meaningful to the patient. In our
experience, this can be done most effectively by a search for the values
most natural and syntonic to the patient-in terms of who he is, what kind
of person he is, and what type of relationship would make the most sense
and be the most rewarding and satisfying to him. Certainly if the patient
has serious theological convictions, including some concept of
afterlife, it is not the function of the therapist to attempt to disturb
them; yet such convictions seldom-for who is not a child of his
age?-obviate the patient's need to explore himself and his relationships
with others. Thus today it is often the psychotherapist who attempts to
help the person who has lost his way-and perhaps the psychotherapist also
who must try to help the person who lives in the shadow of death-to find
his answers to the three questions which, according to leant, it is the
endeavor of philosophy to answer: What can I know? What ought I to do?
What may I hope?
A common basic assumption of psychotherapy
is that the psychotherapist works with a patient to increase the value of
his long-term productivity and his longterm relationships with others,
and, perhaps, to better his adjustment to his environment. Clearly these
are not valid goals for the patient with a fatal illness. But are there
other goals which therapists are committed to, or believe to be part of
their responsibility? Heidegger has suggested that the age of man should
not be reckoned only in terms of how long he has lived, but also of how
long he has to*live.' Within this frame of reference, it is of
major importance what the person is and does during his remaining life
span-that Is, what it encompasses, rather than how long it is in
chronological time. Perhaps life can be seen more validly as an extension
in values than as an extension in time. Here may be an approach
to a philosophy of therapy that does not differentiate patients
according to the length of life left to them-an evaluation which can
never be more than a guess, since the universe gives no one guarantees. If
a person has one hour to live and discovers himself and his life in that
hour, is not this a valid and important growth? There are no deadlines on
living, none on what one way do or feel so long as one is alive.
Thus our point of view in therapy is that
it is important-and indeed it is all that is possible-for the therapist to
help the patient at whatever point he touches the patient's life.
Psychotherapy has generally taken the approach of trying to help the
patient shape his life in the future, and taken the pragmatic view that
results measurable in time are the only basis on which to judge
success. Our view here is rather in tests of the patient’s life, and
respects for it, whatever its time limit.
The patient with a limited life Span has
needs which psychotherapy can potentially fill. Unfortunately, however,
very little therapy has been done, or is being done, with these patients.
This paradox raises certain basic questions. For example, one might well
ask if the more than 3,500 therapy hours, out of which the material
presented here was derived, should have been given to these patients. Was
the work worth doing, since 22 out of 24 of them died during the course of
treatment? In view of the limited number of psychotherapists available,
should this time have been given instead to children or to well young
adults? We are not speaking here of the research value of the
therapy-the findings are published elsewhere • and must be evaluated
within their own frame of reference-but of the value of the therapy in
itself. Was it worth while? Do patients have a right to this type of care
as long as they live, just as they do to physical aid? Perhaps a
comparison of the approaches of clinical medicine and psychotherapy may
be helpful.
In some ways, clinical medicine and
psychotherapy operate according to the same rules and goals, suiting the
therapeutic approach to the needs and potentialities of the patient, and
having as their major goals the easing of pain and the restoration of
function. However, a sharp dichotomy arises at one point. When the
patient's life expectancy is clearly limited, clinical medicine does not
abandon him. Although the physician may be aware that he cannot save the
patient's life or restore his lost functions, he continues to attempt to
soften the blow, to sustain and invigorate him, and to protect him from
pain. Every medical resource is brought to bear on the situation. These
efforts continue as long as the patient lives-and sometimes extend even to
massaging the heart after the patient is technically dead!
Psychotherapy operates quite differently
in this area. So long as the patient's life expectancy is not clearly
limited, it may be possible for him to get psychological help. Once the
termination date is dimly seen, help becomes almost unobtainable. Even if
he can afford private treatment and manages to secure it, the therapist's
reluctance to become involved is likely to be manifested in a quality of
remoteness and detachment which is quite different from his usual
therapeutic approach. This is true not only of the patient with a known
fatal disease, but also frequently of those in the later decades of life.
Viewing this phenomenon on a superficial level, one might come to the
altogether oversimplified conclusion that the therapist's preoccupation
with the patient's continued ability to function and to relate to others
is greater than his preoccupation with the patient himself.
A more careful consideration of this basic
difference between clinical medicine and psychotherapy may make it
possible to see some of the reasons why psychotherapists, by and large,
avoid working with the dying patient, and it may, perhaps, suggest some
implications about the basic values and goals of psychotherapy. There are
many reasons why psychotherapists tend to feel that their task is to help
the patient toward a long and healthy life. They feel that their function
is not only to comfort and support-and in what denigrating terms do many
psychotherapists contrast their cases in "supportive" therapy with those
in "real" therapy!-but also to change him for the future. It may be worth
while to look briefly at the reasons for this.
Each new science, as it develops, tends to
exaggerate its potentialities, to see its future abilities in a somewhat
magical light composed partly of hope and desire, to envision it serving
as elixir vitae answering mankind's greatest questions and needs.
Psychotherapy is no exception-one recalls Freud's vision of answering
the question of the Sphinx. Psychotherapists, in working very hard to
help their patients for the future as well
as in the present, have often forgotten
the unspoken assumption of omnipotence which is
part of this orientation.
Psychotherapists cannot
mold the universe or control the future; they can help the patient now,
in the moment in which they are in contact with him. They may perhaps
need an attitude of more humility
toward their own ability-one recalls someone's definition of psychotherapy
as "the art of applying a science that does not yet exist"-for at present
the death of patients seems to threaten the psychotherapists' basic
assumption of their own omnipotence. Psychotherapy, of course, has never
had any right to expect guarantees from the future. If the
psychotherapist can justify his work only by the results which he assumes
will appear long after he has lost contact with the patient, he had
better think through his basic assumptions.
This need to help the
patient in the future may be strengthened by the psychoanalytic view of
the therapist as a father figure-an image which may be held not only by
the patient, but by the therapist as well. As parents, therapists want
their 'children' to grow up and to have long, happy, mature lives. The
major flaw in this orientation becomes immediately apparent If one looks
at actual parent-child relationships; if a parent receives all, or a major
part, of his satisfactions not from what his child is now, but from what
he will become when he grows up, the relationship clearly leaves much to
be desired.
Certainly it is vitally
important for successful therapy that the therapist wants the very best
for his patient, that he has dreams and visions for him. Only if this is
true, in fact, can the patient learn to accept and value himself, to
really want the best for himself. However, just as these wishes must be
reality-tempered by the potentialities of the patient and his environment,
they must also be tempered by the therapist's knowledge of his own
realistic limitations.
Another reason for the
reluctance to treat patients with a limited life span has been suggested
to us by a psychiatrist colleague. The medical man has, in his experience
in medical school and in his internship, been constantly made to realize
his own helplessness in the face of death. To be highly trained medically,
to have at one's command all modern medical resources, and still to be
unable to save a dying person can be a very heavy blow. Some of those who
are most hurt by this go into psychiatry, where, theoretically, at least,
death does not enter the picture. The prospect of then working with
patients who will die can mobilize all of the doctor's earlier feelings
of defeat and inadequacy, and arouse his resentment and resistance. In
this context, remarks made by several psychiatrists about an earlier
paper on the special problems and techniques involved in psychotherapeutic
work with cancer patients 1•
may be relevant. They did not criticize
the technical concepts presented in the paper, but said that they felt the
idea of intensive psychotherapy with dying patients to be "obscene" and
"disgusting.'•
The fear of the
therapist of his own hurt also seems to be a major factor in the
reluctance to work with the dying patient. The feeling that a therapist
develops for his patient consists of more than countertransference; there
is also love and affection. When the patient dies during the process of
therapy, it is a severe blow. Not only are the therapist's feelings of
omnipotence damaged and his narcissism wounded, but also he has lost a
person about whom he feels very deeply. It is entirely natural to wish to
shield oneself from such an event, which becomes even more painful upon
repetition. We believe, in fact, that a practice composed entirely or
largely of patients with a limited life span is too painful to be dealt
with successfully; treating a small number of such patients seems to be a
much more realistic approach.
The psychotherapist,
too, cannot protect himself by the defense maneuver that necessity
sometimes dictates to the purely medical specialist whose patients often
die-the surgeon, for example, or the oncologist. This defense-the brusque.
armored manner, the uninvolved relationship, the viewing of the patient's
disease as of primary interest and the concentration on its technical
details to the exclusion of as much else of the person as possible-may
save the physician a great deal of heartache, but it is a defense which is
impossible to assume for one who is in a psychotherapeutic role. The
psychotherapist's answer to the heartache
must come rather from a life philosophy
which regards the time left for each person as an unknown variable, and
holds that the expansion of the personality, the search for the self and
its meaning are valid in themselves-valid as a process, valid when they
are being done, and not just in terms of future results.
These are perhaps some of the reasons why
psychotherapists have done so little with patients with a limited life
span-why they have left this painful period of life to the minister, the
rabbi, and the priest. To the question, What can one hope to accomplish
with the dying patient?, our answer is that the validity of the process
of the search for the self is in no way dependent on objective time
measurements, that the expansion of the psyche-in another age, one might
have called it the growth of the soul-is not relevant to the fluttering of
leaves on a calendar.
Some years after his
psychotherapy, a patient wrote:
One of the primacy contributions of the therapy was the
certainty it has provided that I am truly alive ...I can recall the long
years of my life and the full river of emotion that poured through me for
thirty years. Surely I was alone, feeling and suffering intensely, long
before the analysis began. The whole record of my life until then shared
intense fear and anxiety. But there is a difference now, and I believe, it
consists in this: I have became integrated with my life, my body, mind and
psyche are intimately bound to the real world around me; no longer do I
project myself almost completely into the outer world to forget myself, to
avoid the inner fears, panic and uncertainty .... I have the firm
conviction now of being really made of one piece.
A sister of a patient who had died said to
the therapist:
She knew she was loved and lovable before
she died. It was the first time in her life she had been able to accept
this.
A patient's daughter wrote to the
therapist:
. . . and I know that every day she grew in
courage and understanding and was learning
to fight the fears that surrounded her. With a woman like Mother-I
suppose with any human being--an illness such as hers could have been the
final fear to entirely hem veer in and shut her off from human contact.
But I do think that through her work with you. she somehow managed to
WW through her Illness to greater
understanding; not only of herself but of other people too, So please
don't feel that your work was to rain. I don't believe that anything like
that ever goes into a vacuum. Somehow it perpetuates itself. My father and
I are changed because. of the change In Mother. sad I think it Influenced
bar friends who visited her. Because of you, Mother's last months were
filled with hope and thoughts of the future, to her very last hours. And
the past few months were made far easier for those of us who loved her....
because of you, we'll always have a wonderful memory of Mother's last days
and of the courage that fined them.
Of these three patients, two died during
the course of therapy, and one is still alive, years after
completion. Who is to say which of the three therapies was most worth
while?